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WAL-MART PHARMACY 10-1067
CAH451376-00 LAVACA MEDICAL CENTER
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Covered Entity Details
Entity Name
LAVACA MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451376-00
Entity Address
1400 N TEXANA
HALLETTSVILLE, TX 77964-2021
Medicare Provider Number
451376
Participating Start Date
9/30/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1067
Pharmacy Address
1506 N. TEXANA
HALLETTSVILLE, TX 77964
Pharmacy Comments
Contract Details
Approval Date
1/16/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JAMES VANEK, ADMINISTRATOR
(361) 798-3671 Ext: 1207
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/16/2015
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